Issue 4 / 10 February 2014

MUSCULOSKELETAL conditions — both acute and chronic — have become a significant case load in general practice and are linked to much pain and disability in the community. They are also a significant component of health expenditure.
    
According to the Australian Institute of Health and Welfare musculoskeletal conditions were the fourth leading contributor to direct health expenditure in Australia in 2004–2005, at a cost of $4 billion.

The management of some of these cases can be both frustrating and difficult. Many of these patients have already seen physiotherapists, chiropractors and other allied health professionals without much benefit before they end up back on the GP’s doorstep. What options are then available to the GP?

Pain clinics and pain specialists are one option but are usually difficult to access in a timely manner.

Another option is to refer problem musculoskeletal pain cases to a non-specialist medical colleague with an interest in musculoskeletal problems for assessment and treatment.

A group of such doctors — mostly GPs — with an interest in treating acute and chronic musculoskeletal conditions has been active in Australia for more than 40 years under an incorporated organisation known as the Australian Association of Musculoskeletal Medicine (AAMM).

Prominent members of AAMM have included Australian general practice’s leading light, Professor John Murtagh, and pain specialist and researcher, Professor Nik Bogduk, who have contributed much to the development of treatments and the use of evidence-based medicine in the musculoskeletal field. Many AAMM members have postgraduate qualifications such as a diploma in musculoskeletal medicine available in Australia and New Zealand.

Ongoing education is an important part of the association, including an annual scientific conference, with members encouraged to upgrade skills and knowledge so they can provide superior patient outcomes.

AAMM is also active in research and is partly funding a current musculoskeletal research project through Griffith University in Queensland on the treatment of lateral epicondylosis. As detailed in last week’s MJA and reported in MJA InSight, attracting funding for musculoskeletal research is an ongoing problem.

While the most common conditions seen in musculoskeletal medicine are spinal, the discipline also covers a wide range of other conditions including arthritides, tendinopathies, neuropathic pain and regional pain syndromes. Assessment and treatment are multifaceted with consideration of both the biomechanical and the psychosocial factors. They are also carried out with an awareness of the strengths and limitations of clinical assessment and investigations.

Treatments can include evidence-based patient education, manual therapies, specific exercises and a range of injection therapies including trigger point injections, joint and bursa injections of local anaesthetic and steroids (if appropriate), and prolotherapy injections of ligaments and entheses. Dry needling and acupuncture may also be used.

AAMM members also have expertise in the appropriate use of opiates, as a significant number of chronic musculoskeletal pain patients often require such medications. Judicious use of imaging is also emphasised to reduce patient exposure to radiation and cost to Medicare.

Many members have a close working relationship with interventional radiologists, pain specialists, rheumatologists and neurosurgeons/orthopaedic specialists for particularly difficult musculoskeletal cases.

With the prevalence of musculoskeletal conditions in the general population and the burden on the health care system, access to a colleague who has a special interest and skill in this area of medicine to assist with diagnosis, pain and other management is a cost effective and useful option for GPs to consider.

 

Dr Thomas Baster is the president of the Australian Association of Musculoskeletal Medicine and a GP practising in Brisbane.

10 thoughts on “Thomas Baster: Pain options

  1. John Quintner says:

    Perhaps Thomas might like to provide scientific evidence in favour of such therapies as trigger point injections, dry needling and prolotherapy (including its recent off-spring, Neural Prolotherapy). What is the official AAMM position on these procedures? And do its named prominent members support the use of the procedures?

  2. David Lindholm says:

    I have to agree with John. The good work done by the majority is undone by the reputational damage from the so called “needle jockeys”. Please leave the non evidence based procedures to the non medical practitioners. 

  3. dr gary champion says:

    I agree with the above comments. Further,as a Rheumatologist who deals with chronic MSK pain the use of opioids is anathema not only to me but to the majority of my colleagues. To claim special expertise as the AAMM does on the use of opioids is inappropriate.

  4. Dr. Somporn KT, PhD says:

    I agree with some comments. In Thailand we have some modalities to reduce MSD pain by using innovations with no opioids or acupuncture.  I am conducting research under a five year research grant in Thailand. Anyway, I do appreciate to have a session to discuss with friends.

     

     

  5. John Quintner says:

    Anathema is, in my opinion, much too strong a word to use when we are discussing the prescription of opioids in the context of managing people in pain. There are benefits and risks to be considered for each patient and there are well-researched guidelines that are readily available to all medical practitioners. For some with intractable musculoskeletal pain who are intolerant to all other medications, who are often elderly, with a host of co-morbid conditions, a trial of an opioid medication is worth considering, particularly as the transdermal route is now an option.

  6. Dr Margaret Taylor says:

    Recent evidence of prolotherapy for low back pain

    1. 1.Manuel Cusi’s 2010 study: 3 injections of hypertonic glucose to the SI joint – positive clinical outcomes in 76% of patients
    2. 2.Prof Kim’s Korean DB RCT (2010) comparing steroid with glucose injections in SIJ pain confirmed by prior lignocaine injection, showed > 50% pain relief at 15 months in 58.7% with prolotherapy compared with 10.2% with steroid
    3. 3.Watsons report of 190 patients with CLBP refractory to conventional medical management. Pain and Quality of Life – significantly improved at least 1 year after the last prolotherapy treatment.
    4. 4.Wilkinson’s SB crossover study of 35 patients with failed back surgery – lignocaine – good to excellent relief of pain and tenderness in 47% of cases (not bad) compared with 80% with prolotherapy.
      And knee OA – the other scourge of chronic pain in general practice, now 3 DB trials, see Rabago’s 2013 study

    Refs:
    Br J Sports Med 2010;44:100
    J Altern Complement Med 2010;16:1285
    J Altern Complement Med 2010;16:951
    Pain Physician 2005;8:167
    Ann Fam Med 2013;11:229

  7. John Quintner says:

    Hi Margaret. Thanks for listing and summarising the studies. Are they of high quality? Could the results be influenced by such factors as expectation and observer bias etc? These issues need to be discussed in a scientific forum, as I am sure you would agree.

    Of more importance, are you the AAMM spokesperson on prolotherapy, trigger point injections and dry needling?

  8. Thomas Baster says:

    In response to the comment by John Quinter the AAMM does not have any official policy on treatments such as trigger point injections, acupuncture, prolotherapy and some other procedures. Evidence based practice is encouraged but applied by members in different ways as in many areas of medicine. The named prominent or indeed any member do not necessarily support any or all the procedures mentioned and should contacted directly for their views

     

  9. John Quintner says:

    Thomas, may I ask you what role does AAMM fulfill in the management of people with chronic musculoskeletal-skeletal pain? If it takes no position on the scientific credibility of modalities of treatment used by its members, what issues does it discuss and address? Are these modalities of treatment (prolotherapy, dry needling and trigger point injections etc) being taught to attendees of its ongoing educational programmes? 

  10. scott masters says:

    If I may throw in my 2 cents worth ( GP, special interest MSM, post grad qualifications, ex AAMM president)

    AAMM was set up as an educational body and to promote discussion of all matters musculoskeletal – not to be an umpire.

    There seems to be 2 main thrusts to this discussion

    1) Do AAMM members have any special expertise? There qualifications are there to be seen. 

    The National Musculoskeletal Medicine Initiative did compare outcomes  for the management of acute LBP between musculoskeletal medicine Drs following EBM guidelines (which did allow focal injections) compared to a motivated group of general practitoners. The results were published in Spine and are available on the AFMM website. They revealed better long term outcomes for function and pain, at an average cost per patient of 200 dollars less than for GP patients. There are other studies all pointing to multimodal management as the way to go in primary care.

    As for persistent pain –  what mix of management options should be allowed, should be discussed at conferences, what level of evidence is needed before it can be utilised etc will always and should always be an ongoing conversation. All observations welcome

    I would make one point though. If we were to follow strict EBM guidelines such as proposed by Rochelle Buchbinder and colleagues, our radiological colleagues would have to stop the majority of their injections. Buchbinder has also published on rheumatologists and their adherence to EBM guidelines – lets just say there was food for thought in her findings.

     

    2) Does the AAMM release position statements – NO. Thats left to our brother organisation the AFMM

    Lets continue the debate

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